EFTA00313997.pdf

1184674 kaolin* LLC Ac 130 FL (Page 3 ol 3) 3/12/2019 52740 PM µY PERSON MO KNOWINGLY AND WITH Waif TO INJURE, DEFRAUD, OR DECEIVE ANY INSURER FILES A STATEMENT OF CLAW OR AN APPLICATION COP/TARING µY FALSE, INCOMPLETE OR MISLEADING INFORMATION IS GUILTY OF OF THE THIRD DEGREE OR AS OTHERWISE PUNISHASLE AS PROVIDED UNDER DIE LAW. I UNDERSTµD THAT AS THE EMPLOYER, I MUST UPDATE THE APPUCATON MONTHLY TO REELECT ANY CHANGE IN THE REQUIRED APPLICATION %FORMATION ITHE FLORES WORKERS COMPENSATION DOME SHEET WELL BE USED FOR THIS PURPOSE ) F I FEE M APPLICATION OR APPLICATION UPDATE CCRiTAINOC FALSE MIS/ FADING. CR INCOMPLETE WECRMATICN WITH THE PURPOSE OF AVCICINO CR REDUCING DIE ANOINT Of PREMIUM FOR WORKERS COMPENSATION covert/cc IT TS A FELCNY OF THE THRO DEGREE CR 45 OT1121111SE PUNISHASLE AS PROACE0 LADER THE LAW. I SHALL SUOMI TO THE CARRIER, A COPY OF I Ht EMPLOYERS QUARTERLY REPORT MID SELF-AUDITS SUPPORTED BY THE EMPLOYERS QUARTERLY REPORT) AS REQUIRED BY CHAPTER 443, AT DIE END OF EACH QUARTER Islas,' THE MSC OF Ah EATIALOYEE FROM DIS EMPLOYERS OLORTEFLLY REPORT. FLORIDA STATUTES STATE THAT I WC. REMAIN LIABLE AND WILL RE MOURSE THE CARRTER FOR ANY WORREP25 COMPENSADJN BENEFITS PAD TO THIS OMITTED EMPLOYEE; I AGREE TO MARE AVAILABLE. ALL RECORDS NECESSARY FOR THE PAYROLL VERIFICADON ALOT AND PEEWIT THE AUDITOR TO MAKE A PHYSICAL INSPECTION OF CUR OPERATIONS I LWEERSTANO FAILURE TO DO THIS SHALL RESULT N A 5600 PAYMENT TO TIC CARRIER TO CEFRAY THE COST OF THE ALEC& THAT, IN ACCCRDµCE STEN FLORJOA STATUTES 440-131/5), F I ME) UNDERSTATE OR COErELL PAYROLL. OR mEINERNEsENT OR CONCEAL ompLoygE DUTIES SO AS TO AVOID PROPER CLASSMATE:11 FOR PREMLAI CALCULATIONS. OR MISREPRESENT CR CONCEAL NFORMATIOX PERTH ENI TO THE COMPUTATION AND APPLICATOR CO NI EXPERIENCE RATING LIODFCATION FACTOR I DYE) SHALL PAY A PENALTY OF TEN (10) TIES THE AMOUNT Of THE DIFFERENCE RI PREMIUM PAL) MD THE AMOUNT I ENE) SHOULD HAVE PALO. MD REASON ILL ATTORNEYS FEES. FORMER NAVES MD OWNERS FOR THE LAST S YEARS, LIST THE CURRENT BUSINESS NAM µD ANY FORMER NAMES OR PREDECESSOR COMPANIES FOR AL_ CCMPAMES TO RE COVERED BY THE POLICY INCLUDE THE PEN FOR EACH COLEMAN'. FOR EACH COVERED COMPANY. LEST Mn OARENT OWNER WHO -AS MORE THAN 5% CMTENSIIIP INTEREST Fag EACH COVERED COMPANY OR PREDECESSOR COMPANY. LAST NAY OVOIER WHO HAD HIRE THAN 5% OWNER:SHP INTEREST IN THE LAST S YEARS. CWNERSHIP I CCAESHABicry DOES TE48 04ISIXESS OR µY OF THE CWWERS OF THIS BUSINESS. EITHER IMONICLOALY OR N COMBINATION WITH OTHER OWNERS OF THIS BUSINESS OWN MORE THAN 50% OF ANY OTHER BIGNESS, ANKH/ OPERATED AT µY THE CORING THE FIVE YEµS PRIOR TO THIS APPLICATION, I- - YES a NO OR, DOES TIES Er-SWESs OWN A MA.CRITY INTEREST N ANOTHER EMPTY, WIRCHNT-RN OARS A MAJORITY INTEREST IN ANY ENTITY THAT OPERATED r µY TIME IN THE FEE YEARS PRIOR 10 THIS APPLICATION? n YES n NO IF THE ANSWER TO EITHER CF TIE ABOVE QUESTIONS IS YCS. COMPLETE THE MEOWING SUPPLEMENTAL OYWIERSHW / OCARINAS*. ITY QuESTECEES. I Dec lEy BY NAME ACCREss. AND FEIN EAC- MANESS WHICH FS RELATED or comma.. DANERstip TO THE APPLICANT EwsiNtss 2. SET FORTH DE DATES CACH BUSINESS WAS IN OPERATION. THE INSURANCE ccupAwy THAT PROVIDED WORKERS' CCEAPENSATON NS -RMCE. THE POLICY NuMBER AND THE EXPERTENCE WOCKFICATEON FACTCR APPLIED TO EACH SUCH POLICY 1 F THE POLICE, WAS wRTTEN WITHOLLT AN EXPERIENCE MODI RADON FACTOR, P‘LASE STATE, THE APPLICANT HEREBY AUTHORIZES AND REO.ESTS EACH RATING ORGANIZATION µD THE NOSINESS SET FORTH ABOVE TO RELEASE SUCH INFORMATION TO CORRECT VIPER/MEE 1130FICATION FACTOR Cµ BE DETERMINED. WITH I- YFEPIPNCE RATIO INFORAMTON RELATED TO THE APPLICANT THE INSURE.R. POICJUA, OR OTHER RATIWZ ORGµIZATION SO THAT THE I HEREBY ACKNOTILEDGE THAT I HAVE READ THE AbOVE STATEMENTS AND PERSONALLY SWEAR PRAT THE INFORMATION MtTAP/ED IN THE APPLICATION IS ACCURATE. THAT I. AS AN OWNER I OFFICER, AM FLtLY AUTHORIZE() TO SIGN THIS APPIJOATION ON BEHALF OF THE APPOCANT AND TO SEC THE APPLCMT. AB AGENT I PRODUCERI HEREIN Ann? THA- I HAVE GIVEN THE - ar -,- )EIGHNICTRY THE °PPM/LT.1TV TO READ TIE APPLICATION EACI I HAVE EXPLAINED ANY AM ALL WESTON'S REGARDING THE APPLICATION I ALSO ATTEST THAT /HAVE EXPLANED TO THE EMPLOYER OR OFFICER THE CLASSIFICATION COCOS THAT Aft USED FOR PREMIUM CALCULATIONS PURSLµT TO SECTION 440Sn 42) FLORDA STATUTES ONO / BALI Mama RS Fend WC IOW C 8 AA/ <37 rev 0411 NOTATMEUOu0 MEATUS DATE A i Ak-t4A Diu}h lii ii , L -LESLEY K. NOTARY PUBLIC-STATE OF NEW YORK No 01GR6285700 Ovelitied In New YOni County gyeommission Exp•res 07-08.2021 Paw SMS EFTA00313997